Page 1 of 114
COMSAE PHASE 2 FORM 109 — OSTEOPATHIC CLINICAL MEDICINE
BOARD PREPARATION EXAMINATION
Clinical Medicine / Osteopathic Medical Education
COMSAE Phase 2 Form 109-style practice exam covers core clinical
disciplines: Internal Medicine (cardiology, pulmonology,
gastroenterology, endocrinology, nephrology, rheumatology), Surgery,
Pediatrics, OB/GYN, Psychiatry, Emergency Medicine, and Osteopathic
Principles. Emphasis is on diagnosis, management, pathophysiology,
and clinical reasoning across major organ systems.
SECTION 1: INTERNAL MEDICINE & EMERGENCY MEDICINE
QUESTION 1
A 72-year-old man with hypertension and type 2 diabetes presents with
acute onset of severe, tearing chest pain radiating to the back. Blood
pressure is 100/60 mmHg in the right arm and 140/80 mmHg in the left
arm. Which diagnostic study should be ordered first?
A. Transthoracic echocardiogram
B. CT angiography of the chest
C. Electrocardiogram
D. Chest X-ray
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Correct Answer: B. CT angiography of the chest
RATIONALE: The presentation of tearing chest pain with unequal blood
pressures between arms is classic for acute aortic dissection. CT
angiography is the definitive diagnostic study for aortic dissection,
providing rapid visualization of the aorta and its branches. ECG may
show nonspecific changes but is not diagnostic. Chest X-ray may show a
widened mediastinum but is insensitive. Echocardiogram is useful but
CT angiography is more comprehensive and readily available in
emergency settings.
QUESTION 2
A 45-year-old male with hypertension presents with acute onset of
severe, tearing chest pain radiating to the back. Blood pressure is 160/90
in the right arm and 110/70 in the left arm. Which of the following is the
most likely diagnosis?
A. Myocardial infarction
B. Pulmonary embolism
C. Acute pericarditis
D. Aortic dissection
Correct Answer: D. Aortic dissection
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RATIONALE: The classic presentation of acute, severe tearing chest pain
radiating to the back with a significant blood pressure differential
between arms is pathognomonic for aortic dissection. Myocardial
infarction typically presents with crushing substernal chest pain without
blood pressure differentials. Pulmonary embolism presents with sudden
dyspnea and pleuritic chest pain. Acute pericarditis presents with sharp,
positional chest pain improved by leaning forward.
QUESTION 3
A 62-year-old man presents with exertional chest pain relieved by rest.
ECG shows ST-segment depression during pain episodes. Which is the
most likely diagnosis?
A. Prinzmetal angina
B. Stable angina
C. Unstable angina
D. Acute pericarditis
Correct Answer: B. Stable angina
RATIONALE: Predictable exertional chest pain relieved by rest with
transient ST-segment depression is most consistent with stable angina
due to fixed atherosclerotic coronary artery disease. Prinzmetal angina
occurs at rest due to coronary vasospasm. Unstable angina occurs with
increasing frequency or at rest. Acute pericarditis presents with sharp,
positional chest pain.
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QUESTION 4
A patient with chronic obstructive pulmonary disease (COPD) has
worsening dyspnea and a prolonged expiratory phase. Which of the
following physical examination findings is most characteristic of this
condition?
A. Increased tactile fremitus
B. Dullness to percussion
C. Wheezing on auscultation
D. Bronchial breath sounds
Correct Answer: C. Wheezing on auscultation
RATIONALE: Wheezing on auscultation with a prolonged expiratory phase is
characteristic of COPD exacerbation due to airflow obstruction.
Increased tactile fremitus and dullness to percussion suggest
consolidation or pleural effusion. Bronchial breath sounds indicate
consolidation.
QUESTION 5
A 55-year-old woman with type 2 diabetes presents with bilateral foot
numbness and burning pain that worsens at night. Which of the following
is the most appropriate initial pharmacotherapy?
COMSAE PHASE 2 FORM 109 — OSTEOPATHIC CLINICAL MEDICINE
BOARD PREPARATION EXAMINATION
Clinical Medicine / Osteopathic Medical Education
COMSAE Phase 2 Form 109-style practice exam covers core clinical
disciplines: Internal Medicine (cardiology, pulmonology,
gastroenterology, endocrinology, nephrology, rheumatology), Surgery,
Pediatrics, OB/GYN, Psychiatry, Emergency Medicine, and Osteopathic
Principles. Emphasis is on diagnosis, management, pathophysiology,
and clinical reasoning across major organ systems.
SECTION 1: INTERNAL MEDICINE & EMERGENCY MEDICINE
QUESTION 1
A 72-year-old man with hypertension and type 2 diabetes presents with
acute onset of severe, tearing chest pain radiating to the back. Blood
pressure is 100/60 mmHg in the right arm and 140/80 mmHg in the left
arm. Which diagnostic study should be ordered first?
A. Transthoracic echocardiogram
B. CT angiography of the chest
C. Electrocardiogram
D. Chest X-ray
, Page 2 of 114
Correct Answer: B. CT angiography of the chest
RATIONALE: The presentation of tearing chest pain with unequal blood
pressures between arms is classic for acute aortic dissection. CT
angiography is the definitive diagnostic study for aortic dissection,
providing rapid visualization of the aorta and its branches. ECG may
show nonspecific changes but is not diagnostic. Chest X-ray may show a
widened mediastinum but is insensitive. Echocardiogram is useful but
CT angiography is more comprehensive and readily available in
emergency settings.
QUESTION 2
A 45-year-old male with hypertension presents with acute onset of
severe, tearing chest pain radiating to the back. Blood pressure is 160/90
in the right arm and 110/70 in the left arm. Which of the following is the
most likely diagnosis?
A. Myocardial infarction
B. Pulmonary embolism
C. Acute pericarditis
D. Aortic dissection
Correct Answer: D. Aortic dissection
, Page 3 of 114
RATIONALE: The classic presentation of acute, severe tearing chest pain
radiating to the back with a significant blood pressure differential
between arms is pathognomonic for aortic dissection. Myocardial
infarction typically presents with crushing substernal chest pain without
blood pressure differentials. Pulmonary embolism presents with sudden
dyspnea and pleuritic chest pain. Acute pericarditis presents with sharp,
positional chest pain improved by leaning forward.
QUESTION 3
A 62-year-old man presents with exertional chest pain relieved by rest.
ECG shows ST-segment depression during pain episodes. Which is the
most likely diagnosis?
A. Prinzmetal angina
B. Stable angina
C. Unstable angina
D. Acute pericarditis
Correct Answer: B. Stable angina
RATIONALE: Predictable exertional chest pain relieved by rest with
transient ST-segment depression is most consistent with stable angina
due to fixed atherosclerotic coronary artery disease. Prinzmetal angina
occurs at rest due to coronary vasospasm. Unstable angina occurs with
increasing frequency or at rest. Acute pericarditis presents with sharp,
positional chest pain.
, Page 4 of 114
QUESTION 4
A patient with chronic obstructive pulmonary disease (COPD) has
worsening dyspnea and a prolonged expiratory phase. Which of the
following physical examination findings is most characteristic of this
condition?
A. Increased tactile fremitus
B. Dullness to percussion
C. Wheezing on auscultation
D. Bronchial breath sounds
Correct Answer: C. Wheezing on auscultation
RATIONALE: Wheezing on auscultation with a prolonged expiratory phase is
characteristic of COPD exacerbation due to airflow obstruction.
Increased tactile fremitus and dullness to percussion suggest
consolidation or pleural effusion. Bronchial breath sounds indicate
consolidation.
QUESTION 5
A 55-year-old woman with type 2 diabetes presents with bilateral foot
numbness and burning pain that worsens at night. Which of the following
is the most appropriate initial pharmacotherapy?
